Psoriasis

Medical Student Core Curriculum in Dermatology

Last updated March 28, 2011

Module Instructions
The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology. We encourage the learner to read all the hyperlinked information.
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Goals and Objectives

The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with psoriasis. By completing this module, the learner will be able to:
Identify and describe the morphology of psoriasis Describe associated triggers or risk factors for psoriasis Describe the clinical features of psoriatic arthritis List the basic principles of treatment for psoriasis Discuss the emotional and psychosocial impact of psoriasis on patients Determine when to refer a patient with psoriasis to a dermatologist
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Psoriasis: The Basics

Psoriasis is a chronic multisystem disease with predominantly skin and joint manifestations Affects approximately 2% of the U.S. population Age of onset occurs in two peaks: ages 20-30 and ages 50-60, but can be seen at any age There is a strong genetic component
About 30% of patients with psoriasis have a first-degree relative with the disease

Waxes and wanes during a patients lifetime, is often modified by treatment initiation and cessation and has few spontaneous remissions
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Classification of Psoriasis is based on morphology

Plaque: scaly, erythematous patches, papules, and plaques that are sometimes pruritic Inverse/Flexural: lesions are located in the skin folds Guttate: presents with drop lesions, 1-10mm salmon-pink papules with a fine scale Erythrodermic: generalized erythema covering nearly the entire body surface area with varying degrees of scaling Pustular: clinically apparent pustules
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Classification of Psoriasis is based on morphology (cont.)

Pustular psoriasis includes:
Rare, acute generalized variety called von Zumbusch variant Palmoplantar localized involving palms and soles

Clinical findings in patients frequently overlap in more than one category Different types of psoriasis may require different treatment
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What Type of Psoriasis?

A B

Guttate Psoriasis
Acute onset of raindrop-sized lesions on the trunk and extremities Often preceded by streptococcal pharyngitis

Another Example of Guttate Psoriasis

Inverse/Flexural Psoriasis
Erythematous plaques in the axilla, groin, inframammary region, and other skin folds May lack scale due to moistness of area

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More Examples of Inverse/Flexural Psoriasis

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Pustular Psoriasis

Characterized by psoriatic lesions with pustules. Often triggered by corticosteroid withdrawal. When generalized, pustular psoriasis can be life-threatening. These patients should be hospitalized and a dermatologist consulted. 12

Palmoplantar Psoriasis

May occur as either plaque type or pustular type. Often very functionally disabling for the patient. The skin lesions of reactive arthritis typically occur on the palms and soles and are indistinguishable from this form of psoriasis.
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Psoriatic Erythroderma
Involves almost the entire skin surface; skin is bright red Associated with fever, chills, and malaise Like pustular psoriasis, hospitalization is sometimes required
See the module on Erythroderma for more information
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Question
How would you describe these lesions? What type of psoriasis does this patient have?

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Plaque Psoriasis
Well-demarcated plaques with overlying silvery scale and underlying erythema Chronic plaque psoriasis is typically symmetric and bilateral
Plaques may exhibit:
Auspitz sign (bleeding after removal of scale) Koebner phenomenon (lesions induced by trauma)
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More Examples of Plaque Psoriasis

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Plaque Psoriasis: The Basics

Plaque psoriasis is the most common form, affecting 80-90% of patients Approximately 80% of patients with plaque psoriasis have mild to moderate disease localized or scattered lesions covering less than 5% of the body surface area (BSA) 20% have moderate to severe disease affecting more than 5% of the BSA or affecting crucial body areas such as the hands, feet, face, or genitals
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Psoriasis: Pathogenesis
Psoriasis is a hyperproliferative state resulting in thick skin and excess scale Skin proliferation is caused by cytokines released by immune cells Systemic treatments of psoriasis target these cytokines and immune cells

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Case One
Mr. Ronald Gilson

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Case One: History

HPI: Mr. Gilson is a 24-year-old man who presents with a red lesion around his belly button that has been present for one month with occasional itching. He has been reading on the internet and asks: Do I have psoriasis?

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Case One, Question 1

What elements in the history are important to ask when considering the diagnosis of psoriasis?
a. b. c. d. e. Family history Medications Recent illnesses / Past medical history Social history All of the above
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Case One, Question 1

Answer: e What elements in the history are important to ask when considering the diagnosis of psoriasis?
a. b. c. d. e. Family history Medications Recent illnesses / Past medical history Social history All of the above
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Ask About Past Medical History

Psoriasis can be triggered by infections, especially streptococcal pharyngitis Psoriasis can be more severe in patients with HIV Up to 20% of psoriasis patients have psoriatic arthritis, which can lead to joint destruction There is a positive correlation between increased BMI and both prevalence and severity of psoriasis Patients with psoriasis may have an increased risk for cardiovascular disease and should be encouraged to address their modifiable cardiovascular risk factors
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Ask About Medication History

Psoriasis can be triggered or exacerbated by a number of medications including:
Systemic corticosteroid withdrawal Beta blockers Lithium Antimalarials Interferons

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Ask About Family History

There is a strong genetic predisposition to developing psoriasis 1/3 of psoriasis patients have a positive family history However, this means up to 2/3 of patients with psoriasis do not have a family history of psoriasis, so a negative family history does not rule it out
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Ask About Health-Related Behaviors

Studies have revealed smoking as a risk factor for psoriasis Alcohol consumption is more prevalent in patients with psoriasis and it may increase the severity of psoriasis A higher BMI is associated with an increased prevalence and severity of psoriasis
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Back to Case One

Mr. Ronald Gilson Twenty-one year-old man with red lesion around his umbilicus
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Case One: History Continued

PMH: no major illnesses or hospitalizations Medications: none Allergies: none Family history: adopted, unknown Social history: lives with roommates in an apartment, graduate student in physics Health-related behaviors: no tobacco or drug use, consumes 3-6 beers on weekends ROS: negative
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Psoriasis: Clinical Evaluation

Although you should perform a total body skin exam, plaque psoriasis tends to appear in characteristic locations
Key Areas: scalp, ears, elbows and knees (extensor surfaces), umbilicus, gluteal cleft, nails, and sites of recent trauma Observation of psoriatic lesions in these locations helps distinguish psoriasis from other papulosquamous (scaly) skin disorders
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Back to Case One: Skin Exam

Erythematous plaque around and in the umbilicus

Erythematous plaque with overlying silvery scale is present in the gluteal cleft (gluteal pinking)
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Differential Diagnosis of Psoriasis

Mr. Gilson is given a diagnosis of psoriasis based on the clinical evaluation Psoriasis is typically diagnosed on clinical exam because of its characteristic location and appearance Other conditions to be considered in the patient with chronic plaque psoriasis are: Tinea corporis Secondary syphilis Nummular eczema Drug eruption Seborrheic dermatitis
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Case Two
Mr. Bruce Laney

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Case Two: History

HPI: Mr. Laney is a 68-year-old man with a history of psoriasis who presents with increased joint pain and joint changes. He currently uses a topical steroid to treat his psoriasis. PMH: psoriasis x 40 years, hypertension x 20 years Medications: topical clobetasol for psoriasis, hydrochlorothiazide for blood pressure Allergies: none Family history: mother and father both had psoriasis Social history: lives with his wife in a house, retired ROS: negative
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Case Two: Skin Exam

Large erythematous plaque with overlying silvery scale on anterior scalp

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Case Two: Skin Exam

Erythematous plaque with overlying silvery scale at the external auditory meatus and behind the ear

Also with nail pitting

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Case Two: Exam Continued

Erythematous and edematous foot, with dactylitis (sausage digit) of the 2nd digit, and destruction of the DIP joints Onychodystrophy: nail pitting and onycholysis
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Case Two, Question 1

Mr. Laney has psoriasis complicated by psoriatic arthritis. What part(s) of his history/exam are most characteristic of a patient with psoriatic arthritis?
a. b. c. d. History of extensive psoriasis Presence of nail pitting Use of clobetasol All of the above
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Case Two, Question 1

Answer: b Mr. Laney has psoriasis complicated by psoriatic arthritis. What part(s) of his history/exam is most consistent with this diagnosis?
a. History of extensive psoriasis b. Presence of nail pitting (up to 90% of patients with psoriatic arthritis may have nail changes) c. Use of clobetasol d. All of the above
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Psoriatic Onychodystrophy
Nail psoriasis can occur in all psoriasis subtypes Fingernails are involved in ~ 50% of all patients with psoriasis. Toenails in 35% Changes include:
Pitting: punctate depressions of the nail plate surface Onycholysis: separation of the nail plate from the nail bed Subungual hyperkeratosis: abnormal keratinization of the distal nail bed Trachyonychia: rough nails as if scraped with sandpaper longitudinally
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Psoriatic Arthritis (PsA)

Arthritis in the presence of psoriasis
A member of the seronegative spondyloarthropathies

Symptoms can range from mild to severe Occurs in 10-25 percent of patients with psoriasis
Can occur at any age, but for most it appears between the ages of 30 and 50 years It is NOT related to the severity of psoriasis

Five clinical patterns of arthritis occur

Most common is oligoarthritis with swelling and tenosynovitis of one or a few hand joints

Flares and remissions usually characterize the course of psoriatic arthritis

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Psoriatic Arthritis Continued

Health care providers are encouraged to actively seek signs and symptoms of PsA at each visit PsA may appear before the diagnosis of psoriasis If psoriatic arthritis is diagnosed, treatment should be initiated to:
Alleviate signs and symptoms of arthritis Inhibit structural damage Maximize quality of life

Diagnosis is based on clinical judgment

Specific patterns of joint inflammation, absence of rheumatoid factor, and the presence of skin and nail lesions of psoriasis aid clinicians in making the diagnosis of PsA 42

More Examples of PsA

Desquamation of the overlying skin as well as joint swelling and deformity (arthritis mutilans) of both feet

Swelling of the PIP joints of the 2-4th digits, DIP involvement of the 2nd digit
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Case Three
Ms. Sonya Hagerty

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Case Three: History

HPI: Ms. Hagerty is an 18-year-old healthy woman with a new diagnosis of psoriasis. She reports lesions localized to her knees with no other affected areas. She has not tried any therapy. PMH: no major illnesses or hospitalizations Medications: occasional multivitamin Allergies: none Family history: noncontributory Social history: lives in the city with her parents and attends high school Health-related behaviors: no tobacco, alcohol, or drug use ROS: slight pruritus
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Case Three: Skin Exam

Erythematous plaques with overlying silvery scale on the extensor surface of the knee.

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Case Three, Question 1

Which of the following would you recommend to start treatment for Ms. Hagertys psoriasis?
a. b. c. d. e. Biologic (immunomodulators) High potency topical steroid Low potency topical steroid Systemic steroids Topical antifungal
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Case Three, Question 1

Answer: b Which of the following would you recommend to start treatment for Ms. Hagertys psoriasis?
a. b. c. d. e. Biologic (immunomodulators) High potency topical steroid Low potency topical steroid Systemic steroids Topical antifungal
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Psoriasis: Treatment
Since the psoriasis is localized (less than 5% body surface area), topical treatment is appropriate First line agents: high potency topical steroid in combination with calcipotriene (vitamin D analog) Other topical options: tazarotene, salicylic or lactic acid, tar, calcineurin inhibitors
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Psoriasis: Treatment
Factors that influence type of treatment:
Age Type of psoriasis: plaque, guttate, pustular, erythrodermic psoriasis Site and extent of psoriasis: localized = <5% of BSA generalized = diffuse or >30% involvement Previous treatment Other medical conditions
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Psoriasis: Treatment
Patients with localized plaque psoriasis can be managed by a primary care provider Psoriasis of all other types should be evaluated by a dermatologist

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Psoriasis: Topical Treatment

Medication
Topical steroids

Uses in Psoriasis
Plaque-type psoriasis

Side Effects
Skin atrophy, hypopigmentation, striae Skin irritation, photosensitivity (but no contraindication with UVB phototherapy)

Calcipotriene Use in combination with topical (Vitamin D derivative) steroids for added benefit Tazarotene (Topical retinoid) Salicylic or Lactic acid (Keratolytic agents) Coal tar Calcineurin inhibitors Plaque-type psoriasis. Best when used with topical corticosteroids. Plaque-type psoriasis to reduce scaling and soften plaques

Skin irritation, photosensitivity

Systemic absorption can occur if applied to > 20% BSA. Decreases efficacy of UVB phototherapy Skin irritation, odor, staining of clothes Skin burning and itching

Plaque-type psoriasis Off-label use for facial and intertriginous psoriasis

Clinical Pearl
Topical medications for psoriasis are more effective when used with occlusion which allows for better penetration A bandage, saran-wrap, gloves, or socks placed over the medication can serve this purpose

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Case Three, Question 2

What would be an appropriate treatment if a patient had presented with this skin exam?
a. Systemic steroid b. Topical steroid c. Topical steroid and systemic steroid d. Topical steroid and UV light therapy e. All of the above
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Case Three, Question 2

Answer: d What would be an appropriate treatment if a patient had presented with this skin exam?
a. Systemic steroid b. Topical steroid c. Topical steroid and systemic steroid d. Topical steroid and UV light therapy e. All of the above
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Psoriasis: Systemic Treatment

In patients with moderate to severe disease, systemic treatment can be considered and should be supplemented with topical treatment Many patients with moderate to severe psoriasis are only given topical therapy and experience little treatment success
Undertreating the patient can lead to a loss of hope regarding their disease

Oral steroids should never be used in psoriasis as they can severely flare psoriasis upon discontinuation
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Systemic Treatment
There are 3 choices for systemic treatment:
1. Phototherapy: narrow-band ultraviolet B light (nbUVB), broad-band ultraviolet B light (bbUVB), or psoralen plus ultraviolet A light (PUVA) 2. Oral medications: methotrexate, acitretin, cyclosporine 3. Biologic Agents: T- cell blocker (alefacept), TNF- inhibitors (infliximab, etanercept, adalumimab), IL 12/23 blocker (ustekinumab)
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Systemic Treatment
The choice of systemic therapy depends on multiple factors:
convenience side effect risk profile presence or absence of psoriatic arthritis co-morbidities

Systemic treatment for psoriasis should be given only after consultation with a dermatologist
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The Patients Experience

A successful treatment regimen should include patient education as well as provider awareness of the patients experience
Find out the patients views about their disease Ask the patient how psoriasis affects their daily living Ask about symptoms such as pain, itching, burning, and dry skin Ask patients about their experience with previous treatments Important to ask patients about their hopes and expectations for treatment Provide time for patients to ask questions
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Psoriasis and QOL

Psoriasis is a lifelong disease and can affect all aspects of a patients quality of life (QOL), even in patients with limited skin involvement Remember to address both the physical and psychosocial aspects of psoriasis Many patients with psoriasis:
Feel socially stigmatized Have high stress levels Are physically limited by their disease Have higher incidences of depression and alcoholism Struggle with their employment status
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Take Home Points

Psoriasis is a chronic multisystem disease with predominantly skin and joint manifestations About 1/3 of patients with psoriasis have a 1st-degree relative with psoriasis Different types of psoriasis are based on morphology: plaque, guttate, inverse, pustular, and erythrodermic Plaque psoriasis is the most common, affecting 80-90% of patients A detailed history should be taken in patients with psoriasis Plaque psoriasis is often diagnosed clinically Nail disease is common in patients with psoriasis
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Take Home Points

Health care providers are encouraged to actively seek signs and symptoms of psoriatic arthritis at each visit Topical treatment alone is used when the psoriasis is localized Patients with moderate to severe disease often require systemic treatment in addition to topical therapy Systemic treatment includes phototherapy, oral medications and biologic agents Oral steroids should never be used in psoriasis A successful treatment plan should include patient education as well as provider awareness of the patients experience Psoriasis is a lifelong disease and can affect all aspects of a patients quality of life
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Acknowledgements
This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012. Primary authors: Sarah D. Cipriano, MD, MPH; Eric Meinhardt, MD; Timothy G. Berger, MD, FAAD; Wilson Liao, MD, FAAD. Peer reviewers: Peter A. Lio, MD, FAAD; Jennifer Swearingen, MD. Revisions and editing: Sarah D. Cipriano, MD, MPH; John Trinidad. Last revised March 2011.
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End of the Module

Abdelaziz A, Burge S. What should undergraduate medical students know about psoriasis? Involving patients in curriculum development: modified Delphi technique. BMJ 2005;330:633-6. Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462. Bremmer S et al. Obesity and psoriasis: From the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol 2009 article in press. Gelfand JM, et al. Risk of Myocardial Infarction in Patients With Psoriasis. JAMA 2006;296:1735-41. Gottlieb et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 2. Psoriatic arthritis: Overview and guidelines of care for treatment with an emphasis on biologics. J Am Acad Dermatol 2008;58:851-864. Gudjonsson Johann E, Elder James T, "Chapter 18. Psoriasis" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e: http://www.accessmedicine.com/content.aspx?aID=2983780.
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End of the Module

James WD, Berger TG, Elston DM, Chapter 13. Acne (chapter). Andrews Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: 231-239, 245-248. Jobling R. A Patients Journey. Psoriasis. BMJ 2007;334:953-4. Kimball AB et al. The Psychosocial Burden of Psoriasis. Am J Clin Dermatol 2005;6:383-392. Luba KM, Stulberg DL. Chronic Plaque Psoriasis. Am Fam Physician 2006;73:636-44. Menter A et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 1. Overview of psoriasis and guideline of acre for the treatment of psoriasis with biologics. J Am Acad Dermatol 2008;58:826-850. Menter A et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol 2009;60:643-659. Smith CH. Clinical Review. Psoriasis and its management. BMJ 2006;333:380-4.
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